Buena Park Nursing Center

Inspectors wroteBased on interview, facility document review, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and/or worsening of pressure ulcer for one of three sampled residents (Resident 1). * The facility failed to check, turn and reposition every two hours Resident 1 as per the resident's plan of care. This failure had the potential for the resident to develop pressure ulcers and/or worsening of the existing pressure ulcer(s).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1 was changed timely after a bowel movement. In addition, the facility failed to provide a shower when Resident 1 requested to be showered after having a bowel movement. These failures had the potential to result in the resident not receiving necessary care and services and posed a risk for adverse complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent fall for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1 was adequately assisted when turned and positioned during a diaper change in bed to prevent the resident from sliding off the bed and landed on the floor. This failure had the potential to place the resident at risk for more serious injury and compromised resident safety.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with the care and services free from accidents and/or injuries. * The facility failed to maintain Resident 1's skin integrity when provided with care. CNA 1 had long nails and scratched Resident 1 during shower . This failure resulted in Resident 1 sustaining multiple scratches on the head and face and posed a risk for the resident's skin to get infected.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 3, 14, and 16) reviewed for the unnecessary medications were free from the unnecessary psychotropic medication. * The facility failed to implement and document the nonpharmacological interventions for Resident 14 when the resident experienced behavioral episodes associated with the use of Rexulti (antipsychotic medication) and venlafaxine (antidepressant medication). * The facility failed to ensure the orthostatic blood pressure was accurately monitored for Resident 3 related to the use of the psychotropic medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 8 and 110) reviewed for pressure injuries. * The facility failed to ensure the LAL mattress setting was appropriate to the residents' weight for Residents 8 and110. These failures had the potential for the residents to develop pressure injuries or worsening of the existing pressure injuries.

Inspectors wroteBased on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 25 final sampled residents (Residents 3, 4, 7, 21, 69, and 136) and one nonsampled resident (Resident 94 ) reviewed for respiratory care. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Resident 3, 4, and 7. * The facility failed to ensure Resident 69 received the oxygen therapy as ordered by the physician. Additionally, the facility failed to ensure the staff followed the proper infection control practices when a staff member attempted to place a nasal cannula on the resident after it had been on the floor. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menu was followed for 10 residents who received pureed food. * The facility failed to ensure the Korean menu was followed during pureed preparation observation when the cook did not puree one food item (roasted [NAME]) posted on menu, and the cook liquified seaweed soup. This failure posed the risk for the residents who received food prepared in the kitchen to not have their nutritional needs met.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The hairnet for one kitchen staff (Tray Line Staff 1) did not completely cover the hair. * There were ten ladles stored above the three compartment sink, above the wash and rinse sinks. * The facility staff (CNA 6) distributed a food tray to Resident 105 without having the licensed nurse check the food tray. * The kitchen staff (Cook 1) failed to wash her hands after touching a trash can during puree preparation observation. These failures had the potential to cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and facility P&P review, the facility failed to ensure the personal food policy addressed personal food brought in from the outside for the residents who wanted to store and reheat the foods for later consumption. * The facility failed to ensure the residents were able to store food and reheat brought from outside sources in the facility. This failure posed the risk of the residents not being able to choose to store and/or reheat foods brought from the outside and being able to enjoy foods brought from the outside, at their leisure.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for September 2025 through February 2026. The facility failed to ensure the Surveillance Data was accurate to determine whether the resident's infection met the McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria for true infection. * The facility failed to ensure the facility's water system flowchart identified the risk areas in the facility's water flow system where Legionella may grow as per the facility's P&P; [...]

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for one of five residents (Resident 14) reviewed for unnecessary medication. * The facility failed to ensure the informed consent for the venlafaxine (antidepressant medication) indicated the nonpharmacologic measures for Resident 14. This failure had the potential to compromise the resident's and/or their designated representative's right to be fully informed regarding the psychotropic medication and its possible nonpharmacological interventions in order to make an informed decision.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 for one of three residents (Resident 139) reviewed for beneficiary notification. * The facility failed to make sure Resident 139 was provided with NOMNC form prior to discharge from the facility. This failure had the potential for Resident 139 and/or the representative to not be aware of the resident's rights and make informed decision regarding Resident 139's care and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to address the resident's grievance in accordance with the facility's P&P for one of 25 final sampled residents (Resident 81). * The facility failed to address the concern when Resident 81 verbalized the staff was rude and giving attitude when answering his call light. This failure posed the risk for the resident's grievance not being thoroughly addressed, investigated, documented, and resolved.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 98) was free from the physical restraints. * The facility failed to implement the least restrictive measures prior to applying a hand mitten to Resident 98's left hand. In addition, the facility failed to follow and document the release of the left hand mittens as per the physician's order. These failures posed the risk of compromising the residents' independence and psychosocial well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the MDS was accurate for one of 25 final sampled residents (Resident 11). * The facility failed to accurately code the functional limitation of the range of motion for Resident 11. This failure posed the risk for the resident to not receive an individualized plan of care based on their specific needs.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure coordination of PASARR and assessments for one of two final sampled residents (Resident 16). * The facility failed to ensure a follow-up was made regarding Resident 16's PASARR level II recommendation for a psychiatric consult and psychotherapy/counseling services for Resident 16 was completed. This failure posed the risk for Resident 16 to not receive the appropriate care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the level 1 PASRR contained accurate information for one of two final sampled residents (Resident 15) reviewed for PASRR. * Resident 15 had a diagnosis of psychosis; however, the level 1 PASRR showed Resident 15 had no diagnosis of serious mental illness. Additionally, the facility failed to complete a Resident Review when Resident 15's level 2 PASRR evaluation was inaccurate. These failures posed the potential risk for Resident 15 to not receive the necessary care and services as the assessments were inaccurate.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 25 final sampled residents (Residents 6 and 21). * The facility failed to develop a care plan for Resident 6's use of the blood glucose monitoring device (Dexcom G7). * The facility failed to develop a care plan problem to address Resident 21's IV site. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current care needs and interventions for five of 25 final sampled residents (Residents 3, 4, 7, 73, and 98) reviewed for care plans. * The facility failed to ensure the care plan was revised to include the manufacturer's recommendations for cleaning and disinfecting the ventilator machines for Residents 3, 4, and 7. * The facility failed to ensure Resident 73's care plan interventions for weight loss were revised to reflect Resident 73's NPO status; and failed to ensure the care plan for hydration needs related to NPO status was revised to include the current IV hydration therapy. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for three of 25 final sampled residents (Residents 3, 6, and 8). * The facility failed to ensure a physician's order was obtained, the assessment was completed, and appropriate instructions were obtained to maintain the appropriate care of a blood glucose monitoring device (Dexcom G7 - a discreet, all-in-one continuous glucose monitor (CGM) for diabetes management) for Resident 6. This failure posed a risk for the resident to not receive the necessary care and services to maintain their highest physical well-being. * The facility failed to ensure the injection sites for the insulin administration were rotated for Resident 3. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased with insulin absorption. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 11) reviewed for limited range of motion (ROM) received the appropriate treatment and services. * The facility failed to ensure the instruction for the RNA services for Resident 11 was accurate. In addition, the facility failed to ensure the risk of possible ADL decline was explained to the resident when Resident 11 requested to reduce the frequency of the RNA treatment. These failures had the potential to result in the decline in Resident 11's ROM which could lead to further deterioration in the resident's physical well- being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two final sampled residents (Residents 5 and 98) reviewed for tube feeding. * The facility failed to ensure Resident 98 was positioned safely at 30 to 45 degrees during the enteral feeding via G-Tube. * The facility failed to ensure Resident 5's water flush connected via feeding pump was labeled. These failures posed the risk for developing complications related to the residents' GT.

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure professional standards of practice were followed for two of two final sampled residents (Residents 21 and 73) reviewed for the IV therapy. * The facility failed to ensure Resident 21's IV dressing was labeled with the date on when it was placed. * The facility failed to ensure Resident 73's IV tubing was discarded after 72 hours as per the physician's order. These failures posed the risk for the residents to experience complications related to the IV therapy.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for one of 25 final sampled residents (Resident 31) reviewed for pain management. * The facility failed to ensure the hydrocodone-acetaminophen (a narcotic pain medication) medication was administered per the physician's orders for Resident 31. In addition, the facility failed to ensure the nonpharmacological interventions were provided and documented prior to the administration of Resident 31's PRN hydrocodone-acetaminophen medications. These failures had the potential to put Resident 31 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the nurse staffing information was posted in a prominent place accessible to residents and visitors. This failure has the potential of not having the staffing information be available to the residents and the public to determine if sufficient staff were available to care for the residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services. * The facility failed to ensure the administration of the controlled medication for one nonsampled Resident 99 was documented on the MAR. This failure had the potential for the medications to be administered in error and opportunities for drug diversion or drug misuse.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the drugs and biologicals were stored, labeled, and/or disposed properly. * The facility failed to ensure the orally administered medications were stored separately from the externally used medications. This failure posed a risk for the medications to be used or improperly administered to the residents. * The facility failed to ensure the opened box of ipratropium-albuterol (breathing treatment medication) was labeled with the opened date for Residents 83 and 122. These failures posed a risk for the administration potentially contaminated or deteriorated medications. * The facility failed to ensure the vancomycin (an antibiotic) IV medication and supplies were properly disposed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the American and Korean pureed preparation were prepared properly. * The facility failed to ensure the American and Korean pureed food preparation was not conducted too far in advance of the serving time. Also, the staff were not knowledgeable about the serving temperature for kimchi. These failures posed the risk of the foods served losing nutritive value and of the residents not being able to enjoy foods at a palatable temperature.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one nonsampled resident (Resident 33). * The facility failed to ensure Resident 33 was provided with the sippy cup as per the meal ticket and the physician's order. This failure had the potential for Resident 33 not having an appropriate assistive device to properly consume her drinks.

Inspectors wroteBased on interview, facility document review, facility P&P review, and Title 22 review, the facility failed to ensure documented evidence of compliance with the State law. * The sign in sheet for the review of the facility's P&P related to pharmaceutical services failed to include the facility's pharmacist. This failure posed the risk of the P&Ps not being maintained and reviewed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurate for four of 25 final sampled residents (Residents 8, 11, 21, and 73). * The facility failed to ensure Resident 73's Nutrition Risk Assessment was completed accurately. The licensed nurse selected 0 for albumin level of 3.5 to 5.0 g/dL, instead of 3 for albumin level of less than 2.8 g/dL, when Resident 73's albumin level was 2.5 g/dL. * The facility failed to ensure Resident 11's POLST was accurate. The POLST showed Resident 11 had no advance directive, however Resident 11 had an advance directive. * The facility failed to ensure Resident 8's MAR for March 2026 was accurate. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of two final sampled residents (Resident 31) reviewed for hospice. * The facility failed to ensure Resident 31's hospice visitation calendar showed the scheduled hospice staff visits; failed to ensure the hospice nurse, hospice aide, and hospice social worker progress notes were available in Resident 31's hospice binder; and failed to ensure the hospice plan of care was consistent with the actual hospice aide visits for Resident 31. These failures had the potential to put Resident 31 at risk for uncoordinated medical care between the facility and hospice agency.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to accurately determine whether one final sampled resident (Resident 16) who was prescribed antimicrobial therapy and seven nonsampled residents (Residents 34, 45, 76, 78, 99, 117, and 143) met the criteria for true infection. * Residents 16, 34, 45, 76, 78, 99, 117, and 143 who did not meet the McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the care plan was followed for the use of restraints for one of six sampled residents (Resident 6). * The facility failed to ensure Resident 6's left hand mitten was released every two hours as per the care plan. This failure had the potential to cause delays in identifying possible health risks associated with the use of hand mitten restraint including poor circulation and impaired skin integrity.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to one of six sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1's Refresh Plus (eye lubricant), Timoptic ophthalmic solution (a prescription eye drop used to lower high fluid pressure within the eye) and Lumify (an eye drop used to reduce eye redness) were available for administration as ordered by the physician. In addition, the facility failed to ensure Resident 1's physician was made aware when the medications were not available for administration. These failures had the potential to affect resident's health status and wellbeing.

Inspectors wroteBased on interviews, medical record review, and facility document review, the facility failed to develop an individualized care plan for one of five sampled resident (Resident 1). *The facility failed to ensure a care plan was developed for Resident 1's Actual Fall Incident on 11/22/24. This failure posed the risk of not providing the appropriate and individualized care to Resident 1 to prevent another episode of fall.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of five sampled residents (Residents 1 and 2). * The facility failed to ensure the physician's recommendation was carried out as ordered for Resident 1. * The facility failed to ensure Residents 1 and 2's neurological checks (Neuro check -series of tests performed by healthcare providers to evaluate the function of the brain) were completed. * The facility failed to ensure the orthostatic hypotension monitoring was implemented for Resident 1 for the use of the Seroquel (antipsychotic medication). These failures had the potential to negatively affect the residents' well-being as the necessary care and services were not provided.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consents for the use of psychotropic medications for one of five sampled residents (Resident 1) was obtained. * The facility failed to ensure Resident 1's informed consent for the Ativan (anti-anxiety medication) was obtained. This failure posed the risk for the residents to not be informed of their care and treatment.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement effective infection control practices designed to prevent the development and transmission of diseases and infections for seven non-sampled residents (Residents A, B, C, D, E, F, and G) observed for infection control practices.*The facility failed to ensure appropriate enhanced barrier precaution (EBP) signs were posted for Residents A, B, C, D, E, F, and G. In addition, the facility failed to properly train staff to identify the appropriate PPE to don when caring for residents on EBP isolation. These failures posed the risk of not controlling the transmission of infection to the other residents throughout the facility.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to provide the necessary enteral care and services to one of four sampled residents (Resident 1) who had a GJ tube.* The facility failed to ensure Resident 1's enteral feeding was given through the J tube port and medications were given through the G tube port as ordered by the physician. In addition, the facility staff failed to notify the physician when the staff were unable to accurately identify the G and J ports of the GJ tube and provide the in-service training on the care and management of a resident with a GJ tube.* The facility failed to ensure Resident 1 had a physician's order for Resident 1's G tube drainage bag maintenance and discontinuation. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the POLST was signed and dated by the physician and failed to provide an advance directive Acknowledgement form for one of seven final sampled residents (Resident 104) reviewed for advanced directives. This failure had the potential of not following the resident's health wishes and not providing the resident and resident representative the information about the advance directive.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR screening was completed as per the facility's P&P for two of two final sampled residents (Residents 61 and 76) reviewed for PASRR. * The facility failed to ensure Resident 76 had a Level 1 PASRR screening upon readmission back to the facility. * The facility failed to perform a PASRR Level 1 Screening Resident Review Status Change after Resident 61 was diagnosed with depression and prescribed a psychotropic medication. These failures had the potential of not providing the residents screened for mental illness or intellectual disabilities with additional resources if needed.

Inspectors wroteBased on interview and medical record review, the facility failed to develop the comprehensive care plan to reflect the individual care needs for two of 26 final sampled residents (Residents 73 and 88). * The facility failed to develop a care plan to address the use of elevated side rails for Resident 73. * The facility failed to develop a care plan for a high bed for Resident 88. These failures posed the risk for not providing appropriate and individualized care to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the pressure ulcer for three final sampled residents (Residents 3, 102, and 103) and one nonsampled resident (Resident 334) reviewed for pressure injury and skin management. * Resident 334 was developing a new blister to the right underneath first and second toes. The facility failed to assess Resident 334's skin, inform the physician of new change of skin condition, and provide the treatment. * The facility failed to ensure the LAL mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 3. * The facility failed to ensure the LAL mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 102. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of three residents (Resident 74) reviewed for tube feeding. * The facility failed to ensure Resident 74 was connected to the continuous infusing enteral feeding as ordered by the physician. This failure posed the potential risk for not meeting Resident 74's nutritional needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of seven final sampled residents (Residents 8, 44, 58, and 75) and one nonsampled resident (Resident 29) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 75's oxygen was administered as ordered and a No Smoking/Oyxgen in Use sign was outside the resident's door per the facility's P&P. In addition, the facility failed to ensure Resident 75 had a physician's order and care plan developed to address the use of the suction machine. The suction storage bag was also observed undated and unlabeled. * The facility failed to ensure Resident 8 who was on oxygen had a No Smoking/Oxygen in Use sign outside the resident's door as per the facility's P&P. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 82) reviewed for dialysis services. * The facility failed to ensure the dialysis communication forms were completed for Resident 82. This failure had the potential for the resident to experience medical complications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 26 final sampled residents (Residents 46 and 73) remained free from accident hazards. * The facility failed to attempt the alternatives and failed to obtain the informed consent prior to the use of side rails for Resident 73. * For Resident 46, the facility failed to asses for the risk of entrapment and failed to attempt alternatives prior to the use of side rails. Additionally, the facility failed to inform the responsible party of side rail use. These failures had the potential for placing the residents at risk for entrapment for the use of side rails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one of 26 final sampled residents (Resident 74). * The facility failed to ensure Resident 74's GT medication was administered via gravity. * The facility failed to ensure Resident 74's bowel pattern was checked for loose stool/diarrhea prior to administering docusate sodium (stool softener). These failures had the potential to result in poor health outcomes to the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to provide adequate monitoring of the blood pressure and heart rate to ensure one of 26 final sampled residents (Resident 73) was free from unnecessary drugs. * Resident 73 was administered amlodipine (blood pressure medication) and lozartan (blood pressure medication) when the resident's blood pressure and heart rate were not checked prior to administering the medications, as prescribed by the physician. This failure had the potential to negatively affect Resident 73's health condition and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 26 sampled residents (Residents 86 and 124) were free from unnecessary medications. * Resident 124 was prescribed zolpidem (hypnotic) as needed, but this medication was not only limited to 14 days. * The facility failed to ensure Resident 86 was not prescribed quetiapine fumarate (antipsychotic medication) unless the medication was necessary to treat a specific condition or diagnosis. These failures posed the risk of providing residents with unnecessary medications and the potential for development of significant side effects.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure for the safe storage of the medications and supplies for one of three medication rooms (Medication Room A) and five of 10 medication carts (Medication Carts B, C, D, E, and F) inspected. In addition, the facility failed to ensure the medications were not stored at the resident's bedside. * Medication Room A contained multiple expired medications. This failure had the potential to result in the unsafe administration of medications. * The facility failed to ensure the antifungal cream was not kept at Resident 87's bedside. This failure had the potential for unauthorized persons having access to the medication. * Medication Cart D had external and internal medications, and bleach germicidal wipes stored together. This failure had the potential to result in the unsafe administration of medications. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow the food safety and sanitation guidelines in several areas as evidenced by: * The blender used for preparing the pureed food was not air-dried properly. * Two kitchen frying pans showed signs of corrosion. * Staff members (Cooks 1 and 2) lacked the knowledge on proper food cooling procedures. * The storage area for water pitchers and cups was not maintained in a sanitary condition. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's P&P was updated and followed as evidenced by: * The facility failed to ensure the food items in the residents' refrigerator were labeled and dated for one of two resident refrigerators. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure three of 26 final sampled residents (Residents 73, 100, and 124) had accurate and complete medical records. * The facility failed to ensure the information on Resident 73's POLST was accurate and updated. * Resident 100 had conflicting information documented in the medical record as to whether Resident 100 had formulated an advance directive. * Resident 124 did not have a complete smoking assessment and accurate care plan problem for smoking. These failures had the potential of not following the residents' health wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infection when: * The facility failed to ensure LVN 1 changed gloves in between administering medications through a different route. * The facility failed to ensure LVN 1 changed the PPE in between administering medications to two nonsampled residents (Residents 26 and 40) on EBP precautions. These failures posed the risk for transmission of disease-causing microorganisms.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to inform the physician of the residents who had not met McGeer's Criteria and were prescribed antibiotics for two of 26 final sampled residents (Residents 82 and 87) and five nonsampled residents (Resident 12, 25, 57, 83, and 99). This failure had the potential for the continued use of unnecessary antibiotics, potentially resulting in adverse reactions associated with antibiotics, and the development of antibiotic resistant bacteria.

Inspectors wrote2. On 11/19/24 at 1552 hours, a concurrent inspection of Medication Cart F and interview was conducted with LVN 14. There were two glucometers with serial numbers 1040-4306940 and 1040-4381046 inside Medication Cart F. Review of the Quality Control Record for October 2024 showed a calibration log for glucometer with serial number 1040-4381046. However, the calibration log showed missing entries and no calibration was documented from 10/1 to 10/10, 10/12, 10/14, and from 10/20 to 10/28/24. In addition, there was no documented evidence the glucometer with serial numbers 1040-4306940 was calibrated in October. Review of the Quality Control Record for November 2024 showed a calibration log for glucometer with serial number 1040-4261376, which did not match the two glucometers stored in Medication Cart F. [...]

Inspectors wroteBased on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure the call light was within reach for one of 26 final sampled residents (Residents 110). This failure had the potential for Resident 110 not being able to summon help if needed and not receiving care timely.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and homelike environment for one of 26 final sampled residents (Resident 43) and five nonsampled residents (Residents 22, 98, 99, 106, and 117). * Residents 43 and 106 resided in Room E. Room E was observed with the door frame casings in disrepair. * Resident 22 resided in Room A, Resident 98 resided in Room B, Resident 99 resided in Room C, and Resident 117 resided in Room D. Rooms A, B, C, and D were observed with yellowish stains on the residents' curtains. These failures posed the risk for unsanitary and unsightly conditions and had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1 was assessed and monitored by a licensed nurse regarding bruises. In addition, the facility failed to ensure the physician or Resident 1's representative was notified of the bruises. This failure had the potential for not providing necessary care and services for the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was free from the physical restraints. * The facility failed to obtain the informed consent prior to applying the hand mittens (mittens which look like boxing gloves that immobilize the resident's fingers) and physician's order for the hand mitten use; and develop a plan of care related to the use of the hand mittens. This failure posed the risk of compromising the resident's independence and psychosocial well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain a clean and homelike environment for one of four sampled residents (Resident 4). * Resident 4's portable AC unit tubing was observed to be disconnected and lying on the floor, and visible dust particles were observed on the surface of the tubing and floor. This failure had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of two sampled residents (Resident 1). * The facility failed to report Resident 1's sexual abuse allegation to the CDPH L&C Program, Ombudsman office, and local law enforcement agency timely. This failure had the potential for abuse allegations to go unreported and uninvestigated timely.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the allegation of abuse was investigated timely to prevent further potential abuse for one of two sampled residents (Resident 1). * The facility failed to investigate Resident 1's sexual abuse allegation against CNA 1 when the facility received the report of the sexual abuse allegation from Resident 1 on 5/25/24. This failure had the potential to put Resident 1 and other vulnerable residents at increased risk for further sexual abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to conduct a resident change of condition assessment specific to dehydration for one of two sampled residents (Resident 1) whoexhibited signs and symptoms of dehydration as evidenced by: * On 11/27/23 and 12/1/23, Resident 1 ' s family notified the nursing staff of a change in Resident 1 ' s condition which included Resident 1 not wanting to open his eyes or answer questions and Resident 1 ' s family requesting Resident 1 receive hydration. Resident 1 ' s fluid intakes (during the months of November and December 2023) were below the RD ' s recommended daily estimated needs for Resident 1. However, the facility failed to conduct a resident assessment specific to dehydration to determine whether Resident 1 was dehydrated. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the call light system was functioning for one of three sampled residents (Resident 1). This failure had the potential for the delayed provision of assistance to Resident 1.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the sanitary conditions and proper storage of food items were maintained in the kitchen as evidenced by: * The facility failed to ensure the food items were not stored beyond the used by dates. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed affected food items in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure it was safe for one nonsampled resident (Resident 54) to self-administer the medications. * LVN 4 left Resident 54's oral medications at bedside unattended. Resident 54 then took the oral medications without LVN 4's supervision. Resident 54 was not a candidate to safely self-administer the medications. This failure had the potential for Resident 54 to administer the medications unsafely and inaccurately.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was accurate for one of 29 final sampled residents (Resident 60). The MDS failed to show Resident 60 had sustained a fall in the facility. This posed the risk of Resident 60 not receiving an individualized plan of care based on her specific needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were implemented for two of 29 final sampled residents (Residents 48 and 60). * The facility failed to implement the bilateral floor mats for Resident 60 as per the fall risk care plan. * The facility failed to develop a care plan for the use of elevated side rails for Resident 48. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 29 final sampled residents (Resident 60) remained free from accident hazards. * The facility failed to implement the floor mats as per the physician's order for Resident 60. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to meet the needs of six of 29 final sampled residents (Residents 5, 55, 64 78, 81, and 474). * The facility failed to ensure Residents 64 and 78 were placed on the ventilator settings ordered by the physician. This failure had the potential to result in poor health outcomes for the residents. * The facility failed to ensure Resident 474 had a manual resuscitation device (a hand-held device used to provide ventilation to residents who are not breathing or not breathing adequately) at the bedside. This posed the risk of delayed intervention in the event of an emergency. * The facility failed to obtain a physician's order for Residents 5 and 81's supplemental oxygen therapy. This failure posed the risk of the residents receiving unnecessary oxygen. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 29 final sampled residents (Residents 48) remained free from accident hazards related to the use of elevated bed side rails. * The facility failed to ensure Resident 48 was assessed for the risks of entrapment. Also, the facility failed to obtain the informed consent and physician's order prior to the use of bed side rails. This had the potential to place Residents 48 at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8.8%. * LVN 4 failed to administer the correct multivitamin tablet for Resident 54 as per the physician's order. * LVN 5 failed to administer Ciprofloxacin for Resident 67 as per the physician's order. * LVN 5 failed to administer artificial tears for Resident 56 as per the physician's order. These failures had the potential to expose the residents to significant adverse reactions and complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * A bottle of lorazepam (medication used to treat anxiety) oral solution was stored in the medication drawer of Medication Cart 1 instead of being refrigerated as per the manufacturer's instructions. * Multiple opened medication vials with no open dates were observed in Respiratory Cart 3. * One opened medication bottle with no open date was observed in Respiratory Cart 1. * Multiple opened medication containers with no open dates were observed in Treatment Cart 1. * Multiple opened medications containers with no open dates were observed in Medication Cart 1. * LVN 12 left the medication cart unlocked and unattended with the medicine cup containing multiple pills on top of the unlocked medication cart. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical records of two nonsampled residents (Residents 67 and 11) were accurate. These failures had the potential for the residents' care needs not being met as their medical records were inaccurate.